Richard M. Soderstrom

Vaginal douching as a potential risk factor for tubal ectopic pregnancy

The incidence of ectopic pregnancy in the United States has more than doubled in the past decade. Because a previous study has suggested that the practice of vaginal douching may increase the risk of pelvic inflammatory disease, a condition known to predispose to ectopic pregnancy, and because the sale of commercial douching products in the United States has more than tripled since 1974, we investigated this practice as a possible risk factor. We interviewed 155 women who had a tubal ectopic pregnancy treated at five Seattle hospitals between 1975 and 1979 as to their reproductive, contraceptive, and medical histories, demographic characteristics, and personal hygiene practices. During the same period, 456 women who were delivered of a baby in King County were identified from Vital Records and interviewed as controls. A higher proportion of cases than controls reported ever having douched in the past. Cases also douched more frequently than controls. After simultaneous adjusting for confounding factors in our data by means of a multiple logistic regression technique, the risk of tubal ectopic pregnancy for women who douched at least weekly was twice that of women who never douched (95% confidence interval = 1.03 to 4.00). The risk for women who used commercial douches on a weekly basis was 4.4 (95% confidence interval = 1.6 to 12.7) the risk for women who never douched.

Gynecologic endoscopic gas embolism

OBJECTIVE To alert gynecologic surgeons to the risk of room air embolism during endoscopy. DESIGN Case reports. SETTING Medico-legal consultations. PATIENTS Five women having endoscopic procedures. INTERVENTIONS Endoscopy followed by emergency resuscitative measures. RESULTS Morbidity and mortality. CONCLUSIONS The risk of room air embolism may be lessened by attention to the operative technique and by monitoring the end tidal carbon dioxide levels.

Sterilization failures and their causes

To say that a sterilization failure rate is expected does not answer why. Forty-seven cases of repeat sterilization have undergone such surgical and pathologic scrutiny. Resection methods failed most frequently because of spontaneous reanastomosis or fistula formation. Fimbriectomy was particularly vulnerable to reanastomosis because the fimbria ovarica was not removed. Mechanical devices failed when the device was defective, placed improperly, or placed in an improper location. Tissue damage was evident but incomplete when the bipolar electrocoagulation method failures were reviewed, and the endosalpinx remained viable. Unipolar method injuries, in contrast, were complete; they failed by fistula formation. Thus bipolar method failures may occur because of the limited range of electrical power available when using bipolar generators. Some sterilization failures are preventable, but many are not. When medicolegal questions arise, these findings may help answer the question, Why?

One-year results of the Vesta system for endometrial ablation

STUDY OBJECTIVE To compare a distensible multielectrode balloon for endometrial ablation with electrosurgical ablation performed by a combined resection-coagulation technique. DESIGN Randomized, prospective trial (Canadian Task Force classification I). Setting. Eight centers. PATIENTS Women with menorrhagia validated with a standardized pictorial blood loss assessment chart (PBAC), without intracavitary organic uterine disease, who failed or poorly tolerated medical therapy. Intervention. Results in 122 patients treated by Vesta and 112 treated surgically, evaluable at 1 year, were compared, with success defined as monthly blood loss of less than 80 ml and avoidance of additional therapy. MEASUREMENTS AND MAIN RESULTS Pretreatment PBAC scores for patients treated by Vesta and resection or rollerball were 535+/-612 and 445 +/- 313, respectively; at 1 year they were 18+/-37 and 28+/-60, respectively. With PBAC below 75 as the definition of success, 86.9% of Vesta-treated patients were successful compared with 83.0% treated by rollerball or resection. Total amenorrhea, defined as no visible bleeding and no use of protective products, was 31.1% and 34. 8%, respectively. None of the outcome comparisons between treatments showed statistical difference. Complications in both groups were few and minor. Most (86.6%) Vesta procedures were carried out with paracervical block with or without intravenous sedation in an office or outpatient setting, compared with 79.7% epidural or general anesthesia for rollerball or resection. CONCLUSION The Vesta system of endometrial ablation is equally effective and safe as classic resectoscopic methods. Potential advantages include avoidance of fluid and electrolyte disturbance associated with intravasation of distending media, and ability to perform the procedure under local anesthesia in an office setting with less total operating time.

Retreatment with nafarelin for recurrent endometriosis symptoms: efficacy, safety, and bone mineral density☆

OBJECTIVE To assess the efficacy, safety, and effect on bone mineral density of a 3-month course of retreatment with intranasal nafarelin acetate for recurrent symptoms of endometriosis. DESIGN Multicenter, open-label, nonrandomized clinical trial. SETTING Eleven hospital-based and private practices. PATIENT(S) Thirty-six women with endometriosis symptoms recurring after 3 or 6 months of treatment with nafarelin. INTERVENTION(S) Nasal nafarelin 200 micrograms twice daily for 3 months. MAIN OUTCOME MEASURE(S) Assessments for dysmenorrhea, dyspareunia, pelvic pain, tenderness, and induration. Measurement of bone mineral density of the lumbar spine. RESULT(S) Improvements from admission to the end of retreatment were significant for dysmenorrhea, pelvic pain, tenderness, induration, and dyspareunia. Three months after retreatment ended, mean symptom scores for dysmenorrhea and pelvic tenderness, although worse than at the end of retreatment, were still significantly better than scores at admission. Mean bone mineral density 3 months after retreatment was 0.56% lower than before retreatment and 1.94% lower than before initial treatment. CONCLUSION(S) Three-month nafarelin retreatment for recurrent endometriosis symptoms was effective and safe.

Endometrial ablation using a distensible multielectrode balloon

The VestaBlate system uses a multielectrode intrauterine balloon as a device to create effective and safe endometrial ablation (EA). The surface of the distensible balloon is impregnated with thermistors and thin, platelike electrodes. It is designed to deliver low-power electroenergy to the endometrium. Unlike the resectoscope techniques that require nonelectrolytic fluids for uterine distention, moving electrodes at high power outputs, and other variables that are operator dependent, the VestaBlate is computer controlled using a standard type electrosurgical generator. A respiratory enzyme stain, nitroblue tetrazoleum, was used to determine the extent and depth of tissue necrosis to a myometrial depth of 2 to 4 mm with uniform destruction of tissue with power setting at 45 W for a 4-minute application of energy. Sixty-nine patients have been treated, with 45 followed for at least 3 to 9 months. The amenorrhea rate is 40%; the oligomenorhea-hypomenorrhea rate is 49%.

Histologic Changes Associated With Electrosurgical Injury

tures of traumatic injuries on–coagulative-type cell necrosis, more severe in the at than the mucosa abundant capillary ingrowth with rapid white cell n in deposition at the injury site followed by fibroblastic ion reconstruction of the injured muscle coat by 96 hours tures of electrosurgical injuries of capillary ingrowth of fibroblastic muscle coat ction of white cell infiltration except in focal areas at the rder of the injury oagulation necrosis Fig. 1

A History of the American Association of Gynecologic Laparoscopists

After observing Melvin Cohen perform laparoscopy in Chicago, Illinois, during the late 1960s, Jordan M. Phillips performed this revolutionary operation in Downey, California, with enthusiasm. By 1971 he envisioned the need for an independent organization to devote its efforts to promoting this method of surgery through education and training. With the aid of his wife, Eleanor (Ellie), the American Association of Gynecological Laparoscopists (AAGL; a name to be changed slightly later) was incorporated as a not-forprofit entity that year. Based on an exhaustive search of the literature in the United States and Europe, he selected 30 physicians to speak about their experiences at the first meeting held at the Stardust Hotel in Las Vegas, Nevada, in November 1972. Because the AAGL was yet to become an organization of members, the first meeting was appropriately called an annual symposium. It was personally organized, managed, and funded by the Phillips. When one reviews the original program, the 23 speakers and 19 subjects plus 17 luncheon roundtable discussions expose a history lesson in the state of the art of laparoscopy. The keynote speaker was Patrick Steptoe from England, then the author of the only English-language monograph on laparoscopy. Hans Frangenheim of Konstanz, West Germany, a leader in laparoscopic creativity, was the luncheon speaker. As evidenced by a standing ovation, none would argue that the highlight of the meeting was a laparoscopic movie of human ovulation taken by Professor Frangenheim using time-framed 16mm movie film. Anesthesia, basic techniques, and sterilization by laparoscopy were pivotal subjects discussed or presented on film. The potential for infertility investigation was explored, including early operative maneuvers in the form of ovarian biopsy.

Tubal Infertility in Relation to prior induced Abortion

One hundred twenty-seven women who had been given diagnoses of tubal infertility between 1979 and 1981 in King County, Washington, yet previously had been pregnant, were interviewed to determine their prior history of legally induced abortion. Their responses were compared with those of 395 women who conceived a child at the same time the infertile women began their unsuccessful attempt to become pregnant. In making the comparison, we adjusted for the effects of variables that in this population were related both to having an induced abortion and to the occurrence of infertility, i.e., age, number of prior pregnancies, number of sexual partners, cigarette smoking habits, Dalkon Shield (A. H. Robins Company, Richmond, VA) use, and whether the woman worked outside the home. The risk of tubal infertility in women who had had an induced abortion was not increased above that of other women (relative risk, 1.15; 95% confidence interval, 0.70 to 1.89). For women with two or more abortions, the relative risk was 1.29 (95% confidence interval, 0.39 to 4.20). When only the most recent pregnancy was considered, the relative risk was 1.19 (95% confidence interval, 0.72 to 1.97). Our results suggest that legal abortion, as performed during the past decade in the United States, does not carry an excess risk for future tubal infertility.

Toxic Shock Syndrome

a. Symptoms: Toxic shock syndrome is a severe illness characterized by sudden onset of high fever, myalgia, weakness, vomiting, diarrhea, hypotension, diffuse macular erythroderma, and multi-organ system dysfunction. Staphylococcal TSS is often associated with menstruation and tampon use in females and production of TSS-related toxins. Non-menstrual TSS cases have been associated with surgical wound infections, use of diaphragms or contraceptive sponges, and focal staphylococcal infections.